| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
220 |
193 |
$102K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
694 |
689 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
553 |
552 |
$28K |
| D0274 |
Bitewings - four radiographic images |
965 |
962 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,503 |
1,332 |
$20K |
| D1120 |
Prophylaxis - child |
150 |
150 |
$4K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
12 |
$1K |
| D9110 |
|
13 |
13 |
$756.00 |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
39 |
$480.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
50 |
50 |
$426.00 |